AO 78 (10/09)

FEDERAL JUDICIAL BRANCH

APPLICATION FOR EMPLOYMENT
If you need additional space, continue under “Remarks” listing item number
1. Name (Last, First, Middle Initial) 2. Phone Number

3. Present Address (Street, City, State, Zip)

4. Email Address

5. Other Names Previously Used for Employment Purposes 6. Date of Birth (complete only for law enforcement positions)

GENERAL
7. Are you a U.S. Citizen? ’ YES ’ NO If no, give the Country of your citizenship

8. a. Were you ever a federal civilian employee? ’ YES ’ NO If yes, give highest civilian grade: / /
Pay Plan Grade Step

b. Are you receiving a federal civilian annuity payment? ’ YES ’ NO

c. Are you receiving federal severance pay? ’ YES ’ NO If yes, give former agency contact/telephone:

d. Have you received a federal separation incentive payment ’ YES ’ NO If yes, state mo/yr received and former agency contact/telephone:

in the past 5 years?

9. Do you have any relatives who are Judges, Officers or ’ YES ’ NO If yes, give their names, positions, and relationships to you.

employees of the United States Courts?

10. Have you ever served on active duty with the military? ’ YES ’ NO (If selected, you will need to provide your DD-214 (copy 4), Certificate of
Release or Discharge from Active Duty, so that your service may be
verified and credited)

BACKGROUND INFORMATION
For questions 11, 12, and 13, your answers should include convictions resulting from a plea of nolo contendere (no contest), but omit (1) traffic fines of $300 or less, (2) any
violation of law committed before your 16th birthday, (3) any violation of law committed before your 18th birthday if finally decided in juvenile court or under a Youth Offender
law, (4) any conviction set aside under the Federal Youth Corrections Act or similar state law, and (5) any conviction for which the record was expunged under Federal or state
law.

11. During the last 10 years, have you been convicted, imprisoned, ’ YES
on probation, or on parole? (Include felonies, firearms or explosives
violations, misdemeanors, and all other offenses)
12. Have you been convicted by a military court-martial in the past ’ YES
10 years?
13. Are you now under charges for any violation of law? ’ YES
14. During the last 10 years, have you been fired from any job for ’ YES
any reason, did you quit after being told that you would be fired,
did you leave any job by mutual agreement because of specific
problems, or were you debarred from Federal employment by the
Office of Personnel Management or any other Federal agency?
’ NO If yes, provide in Section 19 the date, explanation of violation, place of
occurrence, and name/address of police dept or court.
’ NO If yes, provide in Section 19 the date, explanation of violation, place of
occurrence, and name/address of military authority or court.
’ NO If yes, provide in Section 19 the date, explanation of violation, place of
occurrence, and name/address of police dept or court.
’ NO If yes, provide in Section 19 the date, explanation of problem, reason for
leaving, and employer’s name/address.

15. Are you delinquent on any Federal debt? (Include ’ YES ’ NO If yes, provide in Section 19 the type, length, and amount of
delinquencies arising from Federal taxes, loans, overpayment of delinquency/default, and steps being taken to correct the error/repay the debt.
benefits, and other debts to the U.S. Government, plus defaults of
Federally guaranteed or insured loans (e.g., student loan, home
mortgage loan)).

EDUCATION
16. a. Do you have a high school diploma or G.E.D. equivalent? ’ YES ’ NO If yes, Date of Completion
 Page 2 of 5

Credit Hours Grade Point

b. Name and location of colleges or universities
Dates Attended Degree Date Received Average and/or
attended (including law schools) Quarter Semester scholastic standing

16. c. Other schools or training attended (list name/location of school, dates attended, subject studied, certificates received, and other pertinent data):

JOB RELATED SKILLS, AWARDS, SPECIAL ACCOMPLISHMENTS

17. List any skills (e.g., language, computer, keyboarding speed), honors, awards, or special accomplishments (e.g., memberships in professional/honor societies, leadership
activities, performance awards) that you believe are relevant to your ability to perform the job:

APPLICANTS FOR LEGAL POSITIONS

18. a. Are you admitted to the Bar? ’ YES ’ NO If yes, list the Bar(s) to which admitted and date(s) of admission. If no, skip to

18b.

Is your Bar membership ’ ACTIVE ’ INACTIVE

b. What was your scholastic standing in law school? ’ UPPER ½ ’ UPPER a ’ UPPER ¼
c. Were you a member of an editorial board of law review or a ’ YES ’ No
moot court participant?
19. REMARKS (Use this space for continuation of answers. List the item number being explained.)
 Page 3 of 5

WORK EXPERIENCE

(Start with your present position and work back 10 years. Include any military service. Use additional page if necessary.)
A
Number of hours
Dates of Employment (mm/dd/yyyy) Exact Title of Your Position
worked per week:
From: To:

Pay Plan/Grade
Salary or Earnings Place of Employment
(If in federal Service)
Starting $ Per City
Final $ Per State

Name and Address of Employer (firm, organization, etc.) Name and Title of Immediate Supervisor

Business Telephone: (Area Code and Phone Number)

Reason for Leaving

Description of Work

B
Number of hours
Dates of Employment (mm/dd/yyyy) Exact Title of Your Position
worked per week:
From: To:

Pay Plan/Grade
Salary or Earnings Place of Employment
(If in federal Service)
Starting $ Per City
Final $ Per State

Name and Address of Employer (firm, organization, etc.) Name and Title of Immediate Supervisor

Business Telephone: (Area Code and Phone Number)

Reason for Leaving

Description of Work
 Page 4 of 5

C
Number of hours
Dates of Employment (mm/dd/yyyy) Exact Title of Your Position
worked per week:
From: To:

Pay Plan/Grade
Salary or Earnings Place of Employment
(If in federal Service)
Starting $ Per City
Final $ Per State

Name and Address of Employer (firm, organization, etc.) Name and Title of Immediate Supervisor

Business Telephone: (Area Code and Phone Number)

Reason for Leaving

Description of Work

D
Number of hours
Dates of Employment (mm/dd/yyyy) Exact Title of Your Position
worked per week:
From: To:

Pay Plan/Grade
Salary or Earnings Place of Employment
(If in federal Service)
Starting $ Per City
Final $ Per State

Name and Address of Employer (firm, organization, etc.) Name and Title of Immediate Supervisor

Business Telephone: (Area Code and Phone Number)

Reason for Leaving

Description of Work
 Page 5 of 5

APPLICANT CERTIFICATION

I certify that, to the best of my knowledge and belief, all of the information on and attached to this application is true, correct, complete and made in good
faith. I understand that false or fraudulent information on or attached to this application may be grounds for not hiring me, or firing me after I begin work,
and may be punishable by fine or imprisonment. I understand that any information I give may be investigated.

SIGNATURE DATE SIGNED

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